A comparative microbiological study to assess caries excavation by conventional rotary method and a chemo-mechanical method

Evaluation of antimicrobial photodynamic therapy and minimal intervention associated with deproteinisation in permanent teeth with molar incisor hypomineralisation: study protocol for a clinical, controlled, blinded trial

INTRODUCTION

Molar incisor hypomineralisation (MIH) is a qualitative defect of enamel development that occurs in the mineralisation phase. MIH affects one or more permanent molars and, occasionally, permanent incisors. The aim of the proposed study is to evaluate the clinical effect of antimicrobial photodynamic therapy (aPDT) on permanent teeth with MIH through decontamination and sensitivity control.

METHODS AND ANALYSIS

Patients from 8 to 12 years of age with permanent molars will be randomly allocated to three groups. Group 1: selective chemical-mechanical removal of carious dentinal tissue around the walls of the cavity with Papacárie Duo and a curette followed by the application of aPDT and deproteinisation with Papacárie Duo; group 2: selective removal of carious dentinal tissue around the walls of the cavity with a curette, followed by the application of aPDT and deproteinisation with a 5% sodium hypochlorite solution; group 3: selective removal of carious dentinal tissue using a curette. The selected teeth must have a carious lesion in the dentin and posteruptive enamel breakdown on one or more surfaces with an indication for clinical restorative treatment. The teeth will subsequently be restored using a mixed technique with resin-modified glass ionomer cement and bulk-fill composite resin. The data will be submitted to descriptive statistical analysis. Associations with age and sex will be tested using either the χ2 test or Fisher's exact test. Pearson's correlation coefficients will be calculated to determine the strength of correlations between variables. Comparisons of the microbiological results (colony-forming units) will be performed using analysis of variance and the Kruskal-Wallis test. Kaplan-Meier survival analysis will be performed to assess the performance of the restorations.

ETHICS AND DISSEMINATION

This protocol has been approved by the Human Research Ethics Committee of Nove de Julho University (certificate number: 61027522.0.0000.5511/approval date: 23 August 2022). The findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05443035.

Chemomechanical Caries Removal Methods: A Literature Review

Aim

To provide dental practitioners and researchers with a comprehensive review of the historical development, chemical composition, mechanisms of action, advantages, and drawbacks of different chemomechanical caries removal (CMCR) agents.

Methods

An electronic search was performed for all articles published on CMCR agents in various databases, including the Web of Science, PubMed, Cochrane, Scopus, and Google Scholar bibliographic databases, from January 1, 1975, to July 31, 2022.

Results

Records were identified using the following search terms: Brix3000, Carie-Care, Caridex, Carisolv, chemomechanical caries removal, conventional surgical method, and Papacárie. A total of 171 articles were screened based on the titles and abstracts, of which 126 were deemed eligible for inclusion after duplicates were removed. Following a manual search of the reference list, eight articles were added. Articles were then excluded for other reasons, such as being written before 1975, being written in a language other than English, and the non-availability of the full text. Overall, 120 articles were included in the analysis (literature reviews [n = 27], systematic reviews [n = 8], research articles [n = 82], case reports [n = 3]).

Conclusion

CMCR is a potential method of caries control in the future as an alternative to the conventional surgical approach in standard dentistry applications. It is more widely accepted, less painful, and has comparable efficacy to the conventional surgical method.

Clinical significance

A continuous trend among manufacturers has been observed since 1975 to reduce the drawbacks of CMCR agents. Moreover, evidence-based minimally invasive techniques, including CMCR agents that require minimal or no aerosol-generating procedures, are preferred while measures to control the spread of coronavirus disease are in force.

The impact of minimally invasive restorative techniques on perception of dental pain among pregnant women: a randomized controlled clinical trial

BACKGROUND

The public dental care sector is striving to fulfill the preventive and restorative needs of Egyptians, including pregnant women, who may not receive timely care due to misconceptions about dental treatment during pregnancy. Because of this, they are likely to suffer dental pain, with higher risk of infection affecting their offsprings.

AIM OF THE STUDY

To compare the effectiveness of chemo-mechanical caries removal using Papacarie-Duo and Atraumatic Restorative Treatment (ART) in reducing dental pain among pregnant women.

MATERIALS AND METHODS

A randomized controlled clinical trial was conducted, in 2019, and included 162 pregnant women visiting family health centers in Alexandria, Egypt, with dental pain due to dental caries not extending to pulp. Patients were randomly assigned to Papacarie-Duo group (n = 82) and ART group (n = 80) after stratification by number of treated surfaces. The outcome variables were reduction in pain assessed using Visual Analogue Scale (VAS), satisfaction with treatment, and time taken for dental caries removal. T test/ Mann Whitney U test were used to compare groups and Freidman test was used to compare change across time.

RESULTS

Pain reduction was significantly greater in the Papacarie-Duo than the ART group (81.55% and 69.43%, P = 0.001). Patients in the Papacarie-Duo group were significantly more satisfied with treatment than those in the ART, immediately after treatment (mean = 9.60 and 8.00, P =  < 0.01) and after 6 months (mean = 9.63 and 8.16, P =  < 0.01). Significantly less excavation time was recorded in the Papacarie-Duo group than in the ART group (mean = 10.38 and 11.56 min, P =  < 0.01).

CONCLUSION

Chemo-mechanical caries removal using Papacarie-Duo is more effective in reducing dental pain, in pregnant women, and is associated with more satisfaction and less excavation time than ART.

TRIAL REGISTRATION

ID NCT04573608 ( https://clinicaltrials.gov/ ); 5/10/2020, retrospective registration.

Comparative evaluation of BRIX3000, CARIE CARE, and SMART BURS in caries excavation: An in vivo study

Background:

Chemomechanical caries removal has been a new leaf for caries excavation in this ultraconservative era of dentistry. BRIX3000 & Carie Care are papain based gel formulations while Smart Burs are polymer burs with self limiting ability.

Aim:

To compare & evaluate the caries excavation efficacy of BRIX3000, Carie Care & Smart burs.

Materials & Methods:

45 patients with wide class 1 carious lesions were selected and equally divided into 3 groups: BRIX 3000, Carie Care & Smart Burs. Caries excavation was performed in accordance with manufacturer's instructions in each group & evaluation for reduction in bacterial count & mean working time was done.

Statistical Analysis:

Data was analysed by One way ANOVA, Paired t-Test & Tukey's Post Hoc test.

Results:

The highest reduction in bacterial count was achieved by BRIX3000(156.93 × 10⁴) followed by Smart Burs(139.07× 10⁴)& Carie Care(135.80×10⁴) with p>0.5. Mean working time in minutes for excavation was: BRIX3000(13.66), Carie Care(18.30) &Smart Burs(20.60) with p< 0.5.

Conclusion:

All the techniques reduced bacterial count potentially. BRIX 3000 proves the most effective among three.

Efficacy and Patient's Acceptance of Alternative Methods for Caries Removal-a Systematic Review

Dental caries is a disease of dental hard tissues, considered the most common non-communicable disease worldwide. Conventional treatments for caries removal are often associated with pain and fear, so different therapeutic approaches have been developed towards more conservative and pleasant treatments. This systematic review aimed to assess the efficacy and patient's acceptance of alternative methods for caries removal compared to conventional methods. The Cochrane Library, Embase, Medline/Pubmed, Web of Science, and Clinical Trials databases were searched. Clinical trials of primary dental caries treated with alternative methods were included. The last search was performed on 5 August 2020. The Population, Intervention, Comparison, and Outcome (PICO) strategy was followed. Thirty-seven clinical trials were included, reporting caries removal using alternative (chemomechanical-Brix 3000, Carie-care, Carisolv and Papacarie, laser-Er:YAG (Erbium-doped Yttrium Aluminium Garnet) and Er,Cr:YSGG (Erbium, Chromium-doped Yttrium, Scandium, Gallium and Garnet), and a system combining air and sono-abrasion-Vector^® System) and conventional methods. Alternative methods tended to prolong treatment time and lessen anesthesia need. All treatments were effective in reducing cariogenic flora, and the restoration's performance did not differ significantly. Chemomechanical solutions seemed to be the best option towards minimally invasive treatments, with good control during application and action and good treatment experiences for patients. Papacarie was demonstrated to be an effective method for caries removal with less pain, and superior acceptance by patients when compared to conventional treatments.

Antimicrobial photodynamic therapy on teeth with molar incisor hypomineralization-controlled clinical trial

BACKGROUND

Molar incisor hypomineralization (MIH) is a change in the formation of dental enamel of systemic origin that affects at least one of the first 4 permanent molars and usually affects incisors. During the eruption, the affected surfaces tend to fracture, exposing the dentin, which causes excessive sensitivity in addition to making the region very susceptible to the appearance of carious lesions. The objective of this research will be to evaluate the clinical effect of antimicrobial photodynamic therapy (aPDT) in permanent teeth with severe and sensitive MIH.

METHODS

The methodology will be based on the selection of patients from 6 to 12 years of age with permanent molar teeth, randomly divided in 2 groups. The selected teeth should have MIH on the occlusal surface, indicated for clinical restorative treatment. In Group 1, aPDT will be applied for the treatment of infected dentin. Afterward, the teeth will be restored with high viscosity glass ionomer cement. In Group 2, the removal of the softened dentin around the side walls of the cavity with sharp dentine curettes and posterior restoration with high viscosity glass ionomer cement will be performed. All patients will have clinical and radiographic follow-up with a time interval of 6 and 12 months. The data obtained will be submitted to descriptive statistical analysis to evaluate the association of categorical variables. Chi-square test and Fisher exact test will be applied, to analyze the correlation between the continuous variables, Pearson correlation test will be applied. For the analysis of dentin density in the scanned radiographic images and the microbiological results for colony-forming units, ANOVA and Kruskal-Wallis will be applied.

DISCUSSION

Often in the presence of severe MIH, the presence of dentin sensitivity is also associated with caries lesion, making it even more necessary to respect the principles of minimal intervention.

TRIAL REGISTRATION

NCT03904641.

The effect of antimicrobial photodynamic therapy on infected dentin in primary teeth: A randomized controlled clinical trial protocol

BACKGROUND

Antimicrobial photodynamic therapy (aPDT) has been used for the treatment of dental caries. Papacarie is a gel composed of papain and chloramine employed for the partial removal of carious tissue, effective against bacteria, however, some studies report that this antibacterial action is not quite so evident. The aim of this study is to evaluate the clinical effect of aPDT on infected dentin in dental caries lesion in primary teeth.

METHODS

Thirty-two primary molars with deep occlusal dental caries will be selected and divided in 2 groups: G1 - caries removal with a low-speed drill and G2 - application of aPDT with PapacarieMBlue. After treatment, all the teeth will be restored with glass ionomer cement and followed up clinically and radiographically, with evaluations at 3, 6, and 12 months. Dentin samples before and after treatment will be analyzed microbiologically. The data will be submitted to descriptive statistical analysis of the association between the categorical variables and both age and gender using the chi-square test and Fisher exact text. The Student t test and analysis of variance will be used for the comparison of mean signs and symptoms of reversible pulpitis. Pearson correlation coefficients will be calculated for the analysis of correlations among the continuous variables.

DISCUSSION

Adding methylene blue dye to the formula of PapacarieMBlue might potentiate the antimicrobial action of aPDT and work more effectively on the infected dentin combined with a conservative, minimally invasive treatment.

TRIAL REGISTRATION

NCT02734420 on 10 march 2016.

Effects of Papacarie on children with dental caries in primary teeth: a systematic review and meta-analysis

BACKGROUND

Caries in primary teeth hinder the child to bite and chew and influence their development. Papacarie has the characteristics of selective removal of decayed tissue and can preserve healthy dentine to the maximum, but its efficiency has not been critically evaluated compared to conventional method.

AIM

This review is aiming at comparing the Papacarie and traditional method in caries removal in primary dental caries with children.

DESIGN

Comprehensive literature searching at PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science to January 2018.

RESULTS

Six randomized controlled trials (RCTs) and four prospective controlled clinical trials (CCTs) were included. The microbiota in caries dentine was significantly reduced using the Papacarie treatment (MD = 0.57, 95% CI 0.04 to 1.09, P = 0.03), and the anxiety feeling declined more in the Papacarie group (MD = -1.01, 95% CI -1.72 to -0.30, P < 0.005). There was a greater 200.79 (MD = 200.79, 95%CI 152.50 to 249.09, P < 0.00001) increase in time taken for the Papacarie treatment compared with the conventional method.

CONCLUSION

Papacarie exerts a positive effect in reducing the bacteria and decreases the pain during caries removal in primary teeth although it costed a longer treatment time compared with the conventional method.

Effect of Papacarie and Alternative Restorative Treatment on Pain Reaction during Caries Removal among Children: A Randomized Controlled Clinical Trial

OBJECTIVE

To compare the effect of Papacarie and Atraumatic Restorative Treatment (ART) on pain and discomfort during caries removal among children.

STUDY DESIGN

Fifty healthy, 4-8 year-old children were equally and randomly allocated to Papacarie and ART to remove caries from decayed primary teeth. A randomized, controlled, blinded, two parallel-arms clinical trial was conducted in the clinic of the Pediatric Dentistry and Dental Public Health Department, Alexandria University, Egypt in March 2014. Pain and discomfort were assessed blindly by two independent investigators watching videotaped treatment sessions using the Sound, Eye and Motor scale (SEM). Their reliability was assessed using Kappa statistics. The effect of caries removal methods, time spent to remove caries and other confounders on SEM score was assessed using regression analysis.

RESULTS

Mean time to remove caries using Papacarie and ART was 5.8 and 4.8 minutes, P= 0.005. Median Paparie and ART scores for the S, E and M components were 1, 1, 1 and 3, 2, 3. Adjusted mean SEM score= 3.6 and 7.8, P <0.0001. Method of caries removal was the only factor significantly affecting pain and discomfort.

CONCLUSION

Papacarie is associated with minimal pain during caries removal from primary teeth compared to ART, although it has longer working time.

Caries Removal by Chemomechanical (Carisolv™) vs. Rotary Drill: A Systematic Review

Background:

Chemomechanical caries removal is an effective alternative to the traditional rotary drilling method. The advantages of chemomechanical techniques in terms of the need for anesthesia, pain perception and patient preference are systematically reviewed and a meta-analysis of the time required for caries removal is reported.

Method:

Randomized controlled studies of comparison of chemomechanical techniques with conventional rotary drill were selected from a systematic search of standard biomedical databases, including the PubMed and Cochrane clinical trials. Non-repeated search results were screened for relevance and risk of bias assessment, followed by methodology assessment. Statistical models were applied to the outcome parameters - time required, pain perception, need of anesthesia and patient preference - extracted from the studies.

Results:

Out of the 111 non-repeated search results, 26 studies receiving a low bias score were selected for the review, and 16 randomized clinical trials of rotary and Carisolv techniques were considered for meta-analysis. Meta-analysis by fixed effect as well as random effect models indicate that Carisolv takes more time (3.65 ± 0.05 and 4.09 ± 0.29 min) than rotary drill (8.65 ± 0.09 and 8.97 ± 0.66 min) method. Advantages of reduced pain (14.67 for Carisolv vs. 6.76 for rotary drill), need for anesthesia (1.59% vs. 10.52%) outweigh the longer time requirement and make it the preferred (18.68% vs. 4.69%) method.

Conclusion:

Chemomechanical techniques stand out as a minimally invasive and preferred method based on the meta-analyses. Evaluation of pain experienced using robust methods is needed to strengthen the evidence for their use.

Chemomechanical versus drilling methods for caries removal: an in vitro study

The purpose of this study was to compare the performance of chemomechanical caries removal (CMCR) with that of conventional drilling for efficacy of caries removal, time spent, morphological changes and microhardness of surface dentin, and microleakage of subsequent restorations. Forty-six carious deciduous molars were randomly divided into two groups: one each for caries removal by (1) CMCR and by (2) drilling. The completeness of caries removal was evaluated by visual and tactile criteria and a caries detector device. Twenty teeth in each group were restored with glass ionomer (GI) and subjected to thermocycling before undergoing microleakage and microhardness tests. In each group, three restored teeth were used for polarized light microscopic analysis, and three unrestored teeth for scanning electron microscopy (SEM). There was no significant difference in the completeness of caries removal between groups. However, time spent for caries removal by CMCR was significantly longer than that required for drilling. Restorations in the CMCR group had significantly more microleakage than those in the drilling group. Dentin hardness of the cavity floor after CMCR was also significantly lower. Microscopic analyses showed roughened and irregular dentin surfaces in the CMCR group, unlike the smooth surfaces observed in the drilling group. In conclusion, CMCR was as efficacious as drilling in term of completeness of caries removal, but required longer excavation times and resulted in lower microhardness of residual dentin as well as more microleakage after restorations with GI. Further laboratory and clinical evaluations on the efficiency and performance of CMCR for the durability of subsequent restorations are required.

Effect of papain-based gel on type I collagen--spectroscopy applied for microstructural analysis

Considering the improvement of biomaterials that facilitate atraumatic restorative techniques in dentistry, a papain-based gel can be used in the chemomechanical removal of decayed dental tissue. However, there is no information regarding the influence of this gel on the structure of sound collagen. The aim of the present study was to investigate the adsorption of a papain-based gel (Papacarie^TM) to collagen and determine collagen integrity after treatment. A pilot study was first performed with 10 samples of type I collagen membrane obtained from bovine Achilles deep tendon to compare the influence of hydration (Milli-Q water) on infrared bands of collagen. In a further experiment, 10 samples of type I collagen membrane were used to evaluate the effects of Papacarie^TM on the collagen microstructure. All analyses were performed using the attenuated total reflectance technique of Fourier transform infrared (ATR-FTIR). The results demonstrated that the application of Papacarie^TM does not lead to the degradation of collagen and this product can be safely used in minimally invasive dentistry. As the integrity of sound collagen is preserved after the application of the papain-based gel, this product is indicated for the selective removal of infected dentin, leaving the affected dentin intact and capable of re-mineralization.